A. Medicare is a
federal health insurance program for people age 65 or older and certain
disabled persons. It is run by the Centers for Medicare and Medicaid
Services (CMM) of the U.S. Department of Health and Human Services.
There are two parts, Part (A) and Part (B).
1. Medicare Part A.
Medicare Part (A) pays for inpatient hospital care, limited care in a
skilled nursing facility, home health care and hospice care. If you
are receiving social security benefits you are automatically enrolled
on the first day of the month you turn age 65. Eligibility does not
depend upon income or resources.
2. Medicare Part B.
Medicare Part (B) covers only skilled, not custodial, nursing home
care (42 U.S.C. 1395f(a)(2)(B). Skilled nursing home care is care
1. Ordered by a physician;
2. Required on a daily basis;
3. Performed under the direct supervision
of a licensed nurse;
4. Reasonable and necessary to the
treatment of an illness or injury.
Medicare Part (B) pays for medically necessary doctor
services, out-patient hospital services, home health care and a number
of other services and supplies that are not covered by Part (A). It is
voluntary and requires a monthly premium if you elect to enroll. After a
deductible, Part (B) pays for eighty percent (80%) of the reasonable
charges of coveraged services.
Medicare covers only one hundred (100) days per
"benefit." The patient must be admitted to the nursing home
within thirty (30) days after having been hospitalized and the patient
must have been hospitalized for at least three (3) consecutive days.
The patient must make co-insurance payments for days 21-100.
D. Medicare does
not pay for long term custodial care. Custodial care is care that is
primarily for the purpose of meeting a persons non-medical needs for
mobility and activities of daily living (ADLs). These would include
walking, getting in and out of bed, bathing, dressing, eating and taking
Medicare Supplemental Insurance (Medigap). Medigap
insurance is a health insurance policy designed to supplement medicare.
These are available through private insurance companies and are designed
to supplement Part (A) and Part (B) of medicare. They generally do not
supplement medical expenses not covered by Parts (A) or (B). These
policies are regulated by federal and state law. There are ten different
levels available ("A" to "J") from very basic to
very comprehensive. These policies together with medicare coverage only
pay for the physicians "medically necessary" or
"customary and reasonable" charges. Any excess over this
amount that medicare determines to be an "allowed" charge must
be paid by the patient.
Medicare + Choice. In
addition to medicare, you have a choice of certain medicare managed care
plans (HMO's). There are also several private fee for service plans.
Under the medicare HMO's, you are provided coverage for Parts (A) and
Parts (B) and do not have to pay medicare deductibles or medicare
co-payments. As with any HMO, your choice of doctors and coverage
outside of the HMO service area may be limited. A private
fee-for-service plan allows you to go to any doctor or hospital of your
choice but to be covered by the contractual limits of the plan, you may
need to go to a doctor or hospital that accepts the terms of the plans
A good source of information and assistance is a volunteer
service sponsored by the executive office on aging called "SAGE
Plus." The telephone number on Oahu is 586-7299. You can also
obtain help with medicare questions on a 24 hour hotline
(1-800-Medicare). You may also get information on the net at www.medicare.gov
An excellent resource for information on medicare can be
obtained at www.medicare.gov
A good overview of Medicare coverage can be obtained
from the city and county of Honolulu Elderly Affairs Division book
entitled Deciding "What if?" Go to www.elderlyaffairs.com
and click on the book Deciding "What if?" and scroll to
The center for Medicare and Medicaid services provides a twenty-four
hour a day, seven days a week telephone line to answer your questions
about Medicare. Call 1-800-633-4227. The CMS also publishes a very
useful handbook entitled Medicare and You. You can obtain this
handbook on audio tape, in brail and in large print by calling the same
telephone number. The publication number for this book is CMS-10050.